The Importance of Sleep Education for Mental Health Clinicians

“We are a sleep-deprived society. The CDC has declared insufficient sleep a public health crisis,” observes Nishi Bhopal, MD, founder and medical director of telepsychiatry practice Pacific Integrative Psychiatry.

Psych Congress Network sat down with Dr Bhopal at Psych Congress Elevate 2024 to talk more about how sleep disorder screening, diagnosis, and treatment should be an important element of any medical practice, particularly in psychiatry. She offers insights on why sleep medicine can feel initially overwhelming, how to encourage patients to share more about their own sleep habits, and when psychopharmacological intervention may be necessary.

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Psych Congress Network: One of your passions is making sleep medicine "easy to understand and accessible to all." In your opinion, which topics within sleep medicine do you think would warrant additional review and education for clinicians at this point in time?

Nishi Bhopal, MD: I think most topics within sleep medicine need additional education, and that’s no fault of the clinicians because most physicians only get 0 to 2 hours of sleep education in medical school. But 100% of our patients have to sleep. Particularly in psychiatry and mental health, we know there's a strong bi-directional relationship between sleep issues and mental health issues, but we get such limited training on it as psychiatrists and mental health practitioners. Often the training that we do get is about psychopharmacology for insomnia or maybe a little bit of training on cognitive behavioral therapy for insomnia (CBTI).

There are actually over 80 different sleep disorders. Even with some of the more common sleep disorders, when I speak to colleagues about these, they haven't even heard of some of these sometimes. One example is idiopathic hypersomnia. There's this whole category of sleep disorders under the umbrella of “hypersomnias.” So, there's a lot of education that needs to be done in this area. These are simple things that as a sleep doctor, these are bread and butter issues to us, and we forget that not everyone has that background in training. I think it's important that all clinicians, particularly mental health practitioners and primary care physicians as well, get extra training in sleep medicine.

Psych Congress Network: In your own practice, how do you balance pharmacological treatment and lifestyle interventions when it comes to treating sleep disorders in psychiatric patients?

Dr Bhopal: It really is about first understanding the root cause of the patient's sleep issues. One thing I see a lot is that patients will get diagnosed with insomnia when it actually isn't insomnia. They may be prescribed a sleep aid like Ambien or maybe a benzodiazepine or trazadone when the root cause actually hasn't been elucidated. As psychiatrists, we really need to be aware of the root causes of sleep issues. For example, obstructive sleep apnea can present as insomnia—if we start prescribing medications for the patient's “insomnia,” we might be doing more damage than good. So, the first thing is to look under the hood to see what's actually going on. About 20% of patients with depression have obstructive sleep apnea, so we really do need to have this on our radar.

Now this is not to say that there's no scope for pharmacological interventions for sleep disorders. There is a role for medications to help patients with insomnia and other sleep disorders, but it really needs to be balanced with a root cause analysis. Then, lifestyle adjustment is actually shown to be more effective as an intervention, and there are specific lifestyle interventions that can be helpful for sleep disorders, whether the person's struggling with insomnia or hypersomnia or something in between.

Psych Congress Network: What strategies can clinicians implement to enhance collaboration and communication when treating patients with sleep disorders?

Dr Bhopal: The first thing is really to ask patients about sleep. Most patients do not speak to their doctors about sleep issues, and they generally will not seek out advice for sleep issues. I think the last statistic I saw (it might have changed by now) but the most recent one about only about 5% of patients with sleep issues will go and schedule an appointment to talk to their doctor about it because so many people live with this idea that bad sleep is normal or being tired all the time is normal or being sleep deprived is normal, right? It really has been normalized in our society. We are a sleep-deprived society. The CDC has declared insufficient sleep a public health crisis. One in 3 adults is getting insufficient sleep in the United States. So, just simply asking about it opens up the conversation.

If you don't have time—because I know many of us as clinicians, when you're seeing patients for other issues, there may not be enough time to go into detail about their sleep—I do recommend that every clinician should have it on their pre-screening questionnaire or pre-appointment questionnaire. It can just be part of your workflow that before the appointment, the patient fills out a quick form. You can put some questions on there about their sleep. You can put an Epworth Sleepiness Scale in there, maybe a STOP-BANG questionnaire to screen for sleep apnea and just make it simple.

The other tool that I recommend, and I have information about this on my YouTube channel about how to do this, is called the FIFE model. It's a patient-centered interviewing model and it stands for the patient's feelings, ideas, functioning, and expectations about whatever it is that's going on. So, really just helping your patients open up that conversation, it gets them thinking about it and then you can go from there and see what their goals are and what they might want to, you know, do moving forward.

Interested readers can explore Dr Bhopal's YouTube Channel here.

Nishi Bhopal, MD, is board-certified in psychiatry, sleep medicine, and integrative holistic medicine. She graduated from the University College Cork School of Medicine, completed her psychiatric residency at Henry Ford Health System, and a fellowship in sleep medicine at Harvard Medical School. She is the founder and medical director of Pacific Integrative Psychiatry, an online practice in California where patients receive a whole-person approach to anxiety, depression, and sleep disorders, including nutrition, psychotherapy, and integrative and functional medicine. In addition to her private practice, Dr Bhopal is the founder of IntraBalance, an educational platform for physicians and therapists that includes a YouTube channel and online courses on clinical sleep medicine for healthcare practitioners. Her passion is making clinical sleep medicine easy to understand and accessible to all.